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HomeMy WebLinkAbout1692A . N'ORKERS'CO.MPENSATICN DECIARATlO.'J APPLICATION FOR PLUMBING PERMIT ����Zz � I � I Fereby a`firm i�,a�I hove,o ce��I(Icote of consen��o seli �aqO67A �` t-{ � inzure,or�cer�ifica�e c!Workrrs'Comprtnsntion Insvronce, CE 817(4EV.IOiBI) � ��� or o ce�i�(fIed Qcepy/�he'reo((Sec.J800,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY I P❑olicY NO'.00��41y�Company ���,��C-� ._ . � , . CerY(ied copy�s hereby furnisheJ. FO4 AF.'IIUVT'O FILL IN(PP!VT CR TV7E) BUIIC'HG L L �'Ceri�l�ed copy is filed with the co�niy b�ilding inspec- ne�5cS5 . � E fiondepa�!r+e��. NUMBER FI%TUREORITFM (A fEE '��p��T� Q ,� \�. (� WAIFRCLCSET ��1 'f Da�e ��Applirant� y{y�et�lbh� �:AFEST CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB CRO55 ST. L � 1 -C COMPENSATION INSURANCE Su0'h'iR � 0'NNF� � C � �� (This t�cfien n��d net b�complH�d iF Ih�work invelr�d 6y ti,A�� �hs parml�Is for on�hundr�d dolleri(S100J or Is■■.) iavnrC2r FD7RF55 I cerlify!hcl in�hr, pr.rforma^:n c!�he wcrl:for which�his 1 parmit is issued,I shall not emoloy nny p�rson in any mnnn�r 5'NK [IiY \� !` .EL�� 50(l5�O hflCOTB SUt1�PC��O IhE WC�IfB!S Cnmpensalion Lows. ` ` D:SHWASH[R C04TRACT04 S � •� Do'e A��li[ant � ClOT11E5lNA5HER � ACCR�SS�\, �` l� NOTICE TO APPLICANT: if, oNer mo4ing �his Ceriifico�e of -rT p�ion, you Should become subject �o rf+e Wo�kers' � Su'IM.v.'NGYJCLRFCCCTO4 \ f p .� S pa�sn��o�pmvrt�nns nf iha lahn.Cod•,you mnsi forlh- , c"...' CiTY�\./ \ i' 1"7�1tti� _� � wi�h com I i�h s�ch pe�mii sholl bc �"`�'���-�"�"RLE45'f$�iM �` p y.w p�ovisions or ihis STAiE � deemed re�oked. ,` WATFR HFATER L�CENSf�10. CLAS$ I LICENSED CONTRACTOR$DECIARATION D'STFICf AO F55E�RY I he�eby aNrtm thot I am litensed u�der provisions of Chopler 9 1 Gn55v5TEM s oJ1tET5 \ � ^(�(\ �M_ n i (commanc�ng w�ih Sec��on 7000)ot D��ision 3 oi�tie Bus�ness ouliFisovfe ��� .��� and Professions Code,ond my I�cense is in full force and eiieci. 5 aFu SrS7EM FINAL VALIDATiON I 1`^ �t -7 DATE ��f l�✓ � n�".' License Number`� 11��`� Lic.Class �J O \ �� BY AL U. I Conlracto��G�+e�1-�Olns Date t.t,. (..+' I � I am e.e�A��^�e�Sec. � U iB.BP.C.tor�h�s reason Plon check fee , N� D���� PtUM81NG PER.MIT ISSUING FEE S „Z,� Signo•ure TOTAL FEE Pl�n chetk oppl��ont SINGLE FAMIIY HOME OWNER-BUILDER DECLAPATION Nnme � eby affirm�he�I om evempl fror�the Con+roc�or's License n�a.rss yr(or 1he}ollowin�reosnn(Sec�ien 7031.5,Business and ' � ofassions Code)� City Tel.No. ❑ I,os owner of rl,e prope��y,w�ll do ihe wo�k and�i,� �'� �''�•��• structure�s no��ntended or offe.red fer sole (Sect�on ► � 70n4,Bus�ness and Prolexsicns Code). ��" e • � •:: COhSTRUCTION tEND'nG AGfNCY � e � � ��,� I heraby nffirm thot there is a mns�rucrion Iend�ng oqxncy(cr the pariermance c(the wnr4 for which ihis pe�mil is issur.d . ., : � � ; �7 T . i. (Set.�097,Civ.C.). ne�s_s<�, Lendr.r's N�me � � v V Lecder's Address I cr,ri�{y�tict I h�ve reod�h�s e^nl�cof�on and sla'r Iho1 rhe ► cbove info�r+a�ion is cr.rrccL I agrer.io ccmply with o!I Cour.�y � ord�nnncr.s r.nd 5'a'e lows reguloting Plumb�ng,o�d horeby ou'horize represen�a��ves of this County ro entcr upon t!•c nbo�e-m=�fiened prepe�iy for fnsn^cfinn pu�ncses. n / SEE REVERSE FOR EXPIANATORY IANGUAGE 7S^Z�—�l-� S�gna�ure 1 Parmi . Dn�rs G� G1 ,F•.'J 1 V -,� S Z, � C U r. c � �' c� 'i. . � ' N ._ , � > i „ ; {r � . � -� - y u;�� rn �� c �, r1 �� � `� 'o � r� ..r� O ... _. i:� �� � '�1• l Xi ^y'' � �j', in K'�_ � (� C� rl � .r �; N �� v -.� �'� . 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